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Fasciotomies of the calf for exertional compartment syndrome

    Overview

    Learn the Fasciotomies of the calf for exertional compartment syndrome surgical technique with step by step instructions on OrthOracle. Our e-learning platform contains high resolution images and a certified CME of the Fasciotomies of the calf for exertional compartment syndrome surgical procedure.
    Chronic exertional compartments syndrome (CECS) of the lower limb is a condition that is generally under-diagnosed and presents with characteristic symptoms in at risk populations, such as athletes and military recruits.
    CECS is characterised by exertional leg pain, which may be variably associated with pain, swelling, loss of function and distal cutaneous numbness related to specific muscle muscle compartments. The most commonly affected compartment is the anterior compartment of the lower leg(51%) followed by the lateral compartment(33%), the deep posterior compartment(13%) and superficial posterior compartment(3%).
    Signs and symptoms tend to be localised to the involved muscle compartments. Presenting symptoms include cramping, aching, a feeling of muscles tightness, numbness and tingling, foot drop (often reported as slapping of the foot), and occasionally local swelling or bulging as a result of muscle herniation. These symptoms often occur in a recognisable temporal pattern in a patient, after a consistent time, distance or intensity of exercise. The pain classically becomes worse as exercise progresses, and is usually sufficiently debilitating to require an individual to stop. The symptoms reduce once exercise is stopped and have often resolved within fifteen minutes of cessation. If activity is re-commenced after a brief rest, patients commonly report a reduced length of time prior to onset of further symptoms.

    Indications

    INDICATIONS
    The indication for compartment release in Chronic Exertional compartment Syndrome (CECS) is persistent debilitating pain affecting the patient’s activities, confirmed on pressure manometer testing, that has not responded to non-operative management, including physiotherapy, footwear modification, activity reduction and gait retraining.
    SYMPTOMS & EXAMINATION
    Patients present with symptoms of increased pressure sensation, pain, aching, cramping and occasionally burning in the effected compartment (usually the anterior compartment), that occurs after a consistent period of time of a given provocative exercise. Symptoms resolves with rest however if exercise is re-commenced too quickly, the lag period before onset of symptoms may reduce. There is often numbness and tingling associated with the nerve that passes through the involved compartment, in the case of the anterior compartment this will be the superficial peroneal nerve and might cause numbness over the dorsum of the foot.
    Patients’ will complain of increasing weakness of the limb during exercise and this often manifests itself as feeling of the foot slapping when running. This phenomenon is the result of loss of function in the tibialis anterior muscle due to ischaemia, resulting in a temporary foot drop. The symptoms are frequently bilateral. Muscle herniation can also be associated with CECS syndrome which manifests itself as discreet swellings or bulges in the compartment which become worse with exercise.
    CECS is not symptomatic when the patient is at rest or performing lower intensity activities, which will help distinguish it from its differential diagnoses.
    INTRACOMPARTMENTAL PRESSURE MEASUREMENTS:
    The diagnosis of CECS is extremely difficult to establish based on clinical criteria alone; in patients who present with signs and symptoms of chronic exertional compartment syndrome, pre and post exercise intracompartmental pressure measurement is a safe and reliable method of increasing diagnostic accuracy. Whilst there remains some debate regarding pressure thresholds and timing of measurements, most of the described diagnostic criteria are based upon the Pedowitz modified criteria(Am J Sports Med. 1990 Jan-Feb;18(1):35-40). The Pedowitz group proposed that in patients with positive clinical findings, one or more of the following intramuscular pressure criteria were likely to be diagnostic of CECS of the leg
    1) a pre-exercise pressure greater than or equal to 15 mm Hg,
    2) a 1 minute postexercise pressure of greater than or equal to 30 mm Hg, or
    3) a 5 minute postexercise pressure greater than or equal to 20 mm Hg.
    IMAGING
    Weight-bearing radiographs maybe helpful in excluding degenerative change, stress fractures, deformity, or abnormalities around the syndesmosis, such as osteochondromas or heterotopic ossification. Plain MRI scans rarely show any significant abnormality, although some studies of post-exercise MRI scans suggested that post exercise scans might have an application in future diagnosis as they demonstrate subtle, characteristic abnormalities in the research non-clinical setting. MRI scans are also useful when excluding periosteal reaction or stress fractures, which maybe a differential diagnosis of CECS. Technecium bone scans or spect CT scan maybe helpful in showing more subtle periosteal reactions, which can be seen in medial tibial stress syndrome or shin splints.
    ALTERNATIVE OPERATIVE TREATMENT
    Fasciotomies of the lower limb are an established method of treatment for CECS, the procedure can be performed in a variety of manners. Traditionally a long incision has been used, more recently a small single incision, 2 incision technique and an arthroscopic technique have been described. My experience is that a long incision is often unnecessary and is associated with an increased risk of wound problems and dehiscence and a slower recovery time when compared to a small single incision, whilst occasionally patients with longer lower limbs will require a 2 incision technique. The arthroscopic technique carries a an increased risk of nerve damage. In those patients with herniation of tibialis anterior through defects in the deep fascia, a fasciotomy is performed in a similar manner to the standard fasciotomy, the fascial defects should not be repaired, as this will not treat the raised intracompartmental pressure which is often associated with the condition.
    NON-OPERATIVE MANAGEMENT
    A number of studies have looked at gait retraining. Roberts (J R Army Med Corps. 2015 Mar;161(1):42-45) and Sugimoto (J Phys Ther Sci. 2018 Aug;30(8):1056-1062) found different gait patterns in patients with CECS compared to controls which included increased ankle dorsiflexion in swing phase, tendency towards longer step length, longer stance phase and pronounced heel strike in patients with CECS.
    Zimmerman (BMJ Open Port Exerc Med. 2019 Mar 19;5(1)) reported a cohort of military patients with CECS who were enrolled on a physical therapy and gait retraining programme emphasising forefoot loading and found 57% improved, and had returned and maintained their usual activities at 2 years.
    DIFFERENTIAL DIAGNOSIS
    The differential diagnoses for chronic exertional compartment syndrome include medial tibial stress syndrome(shin splints), popliteal artery entrapment syndrome, acquired myopathies and rarely anterior compartment soft tissue tumours.
    CONTRAINDICATIONS
    Patients with underlying myopathies tend to respond poorly to compartment release, the author’s tend to perform a routine creatine kinase (CK) as a basic screen for myopathy. Active Infection, Peripheral vascular disease and peripheral neuropathy are contraindications..

    Setup

    The patient is positioned supine on the table, as the lower limb generally tends to externally rotate, a sandbag under the affected ipsilateral buttock helps internally rotate the leg and expose the anterior and lateral compartments.
    A thigh tourniquet is used to provide a bloodless field and the patient is cleaned with a sterile alcoholic preparation to above the knee.
    Instruments: A basic orthopaedic set with scalpel, skin retractors, blunt tipped dissection(McIndoes) scissors, a smiley fasciotomy knife, as well as a sterile ruler.

    Operation – 1

    Compartment pressure measurements using the following investigative steps are performed well in advance of the planned surgery to assist in diagnosing the condition.
    Proper sterilisation of the skin before pressure manometer testing of the compartment should be performed pre and post exercise.

    Local anaesthetic is drawn up in a sterile syringe and is infiltrated in a broad area subcutaneously over the anterior and lateral compartments of the calf, where measurements are to be made.

    A 2 ported diaphragm chamber, 18 gauge needle and syringe filled with 3ml of saline are required to attach to the pressure monitor.

    The 2 ported diaphragm chamber is attached on one port to the 18 gauge needle and the saline filled syringe on the other.

    CPlace the diaphragm chamber assembly into the pressure monitor, black side down, gently push until it is well seated., the front cover is closed and the latch should click, this shouldn’t be forced. The pressure monitor should be zeroed

    Air should be evacuated from the syringe and chamber, by pointing the needle vertically, at least 45 degrees and gently compressing the plunger with the thumb.

    The pressure monitor is switched on by sliding the black button on the top left of the device. it should read between 0 and 9. The device is re-calibrated to zero, by holding the device at the same angle as it will be inserted into the muscle compartment and then pressing the blue button seen here to the left of the display. the device display should read “00”.

    Pressure measurement: the needle is inserted into the desired compartment, no more than 0.3ml of saline is injected once the needle is located, and the examiner then waits for the device to record and display the pressure. Pressure measurements are performed immediately prior to exercise and then 1 and 5 minutes after symptoms are provoked following exercise.
    The pressures should be carefully documented.

    A sterile plaster is placed over the wound measuring site.

    Define the anatomical landmarks: the lateral fibula, anterior border of tibia and tip of the fibula are marked.The tip of the fibular, and then 13cm proximally,the anterior border of tibia and the fibula are identified and marked with a surgical pen.

    The level of the incision is based at a point 13cm proximal to the tip of the fibula and marked.A sterile ruler is used to measure a point 13cm proximal to the fibula, which should be midway between the anterior border of the tibia and the subcutaneous border of fibula. A 3-4 cm longitudinal line is then drawn centred at this point using a surgical marker.

    The skin incision is placed midway between the anterior border of tibia and fibulaThe incision is longitudinal and centred over the lateral part of the anterior compartment.

    The incision is made through the predetermined mark. During the skin incision, care should be taken not to penetrate too deeply, as the superficial peroneal nerve is located directly under the superficial fascia.

    The incision is carefully developed, taking care not to penetrate too deeply as the superficial peroneal nerve lies immediately deep to the subcutaneous fat.
    It penetrates the deep fascia approximately 13cm proximal to the tip of the fibular midway between the anterior border of the tibia and fibula, where it is at risk of being damaged.

    The deeper layer of superficial fascia is divided bluntly with a Mcindoes scissors down to the deep investing fascia.The plane between the Superficial fascia and deep fascia should be gently teased open, the surgeon should be cognisant of the proximity of the underlying superficial nerve

    The deep investing fascia now exposed, the superficial fascia is swept away with blunt dissecting forceps or the blunt handle of the scalpel to produce a pocket.The superficial fascia is carefully dissected away from the underlying fat creating a pocket, taking care to protect the superficial peroneal nerve which should be carefully identified, it can be seen running longitudinally, proximally, lying deep to the investing fascia, before penetrating the fascia and lies superficially as it passes distally.

    Any deep penetrating vessels should be protected if possible, to avoid devasculairisng the overlying skin which may affect wound healing.

    The superficial peroneal nerve is carefully exposed. At the level of the incision, once the superficial fascia has been dissected, the nerve will variably be seen lying deep to, emerging from or superficial to the deep investing fascia.As the superficial peroneal nerve passes distally it goes from lying deep to the deep investing fascia, then penetrates the deep investing fascia (at approximately 13cm proximal to the tip of the fibula) As it emerges from the fascia there is often a small surrounding cuff of fatty tissue.
    As it passes distally it lies in a plane superficial the deep investing fascia and deep to the subcutaneous fat.

    The superficial peroneal nerve is then followed distally as it emerges from the deep fascia to lie superficial to it, as it emerges it is often surrounded by a cuff of fatty tissue.The superficial peroneal nerve is traced distally, normal variants include a bifurcation or trifurcation of the nerve, which are occasionally seen, the branches should be carefully protected as injury can lead to paraesthesia or neuropathic pain over the dorsum of the foot.

    The Superficial Peroneal nerve is marked with a sling to help protect it.Once the peroneal nerve has been found emerging from the fascia, it is helpful to mark it with a (yellow) sling. This helps to clearly demarcate the nerve which helps avoid iatrogenic injury.

    Create a tunnel between the superficial fascia and the deep investing fascia using blunt dissection scissors. This will allow a free passage of the smiley knife when the facia is released.This tunnel helps reduce the chance of iatrogenic damage to the superficial fascia, penetrating vessels and the superficial peroneal nerve.

    Extend the tunnel superficial to the deep investing fascia to the full proximal extent of the intended fasciotomy. A tunnel superficial to the deep investing fascia should be developed in its proximal extent, in order to aid complete release of the compartment. The authors use a blunt pair of dissection scissors which are passed from distal to proximal, along the superficial surface of the deep investing fascia until the tips are adjacent to the proximal extent of the anterior compartment, before being opened and withdrawn whilst open to create a space between deep and superficial fascia.

    The proximal fascial pocket is digitally dissected.The pocket is created further using a blunt dissection using the surgeon’s index finger.This creates a space to allow a skin retractor to be positioned which allows direct visualisation of the first part of the fascial release.

    Incise the fascia of the anterolateral compartment to create an entry point for the Smiley knife.The deep investing fascia is punctured under direct vision with the superficial peroneal nerve identified and protected.
    A small incision is made in the anterior compartment fascia, anterior to the superficial peroneal nerve, making sure not to cut the underlying muscle.

    The deep fascia of the anterior compartment is tensioned using an artery forceps.The small incised anterior margin of the deep fascia is grasped with an artery clip providing some counter traction during the release of the fascia.

    Operation – 2

    A plane is developed between the deep surface of the deep investing fascia and the underlying Tibialis Anterior muscle.A McIndoes scissors are used for blunt dissection of the muscle away from the deep surface of the fascia along the line of the intended passage of the smiley knife, in order to minimise the risk of damage to the tibialis anterior muscle during the fascial release.The McIndoes scissors are passed to the proximal extent of the fascia.

    The tip of the smiley knife has a shorter and longer prong. It is the longer of its 2 prongs that will be passed deeply.

    The Smiley knife is laid against the leg the tip is aligned with the proximal margin of the compartment, in order to gauge how far it will need to be inserted to permit release of the entire compartment.

    The Smiley knife has a slight anterior curve and this should be orientated away from the nerve, in the case of the anterior compartment, this helps ensure that the blade passes anterior and continues to pass anterior to the more posteriorly located superficial peroneal nerve, reducing the potential for iatrogenic damage.

    The smiley knife is passed with the longer blade, deep to the fascia of the anterior compartment, its curve directed away from the nerve.(anteriorly).The smiley knife is passed with its longer blade deep to the fascia, on the side of the tibialis anterior muscle.
    The smaller prong of the blade sits superficial, on the side of the subcutaneous fat, and counter traction is maintained with the artery clip.

    The smiley knife is passed in one clean sweeping movement from distal to proximal maintaining pressure on the thumb piece of the knife. There is tactile feedback of resistance as the deep fascia divides.

    The release of the full length of the deep investing fascia is achieved in one smooth pass of the Smiley knife.Pressure is maintained on the smiley knife as it is passed proximally. There is a characteristic tactile feedback as the fascia is divided (similar to the feeling one gets when cutting fabric with a pair of scissors).
    The knife needs to be passed to the predetermined length, which will often involve passing the thumb piece into the incision site
    This should be done using one continuous movement, avoiding disengaging the knife from the fascia (which may lead to an incomplete release, multiple passes can leave residual fascial bands).

    The smiley knife can be seen passed maximally here and the tip of the blade can be felt right at the proximal margin of the fascia.

    Incise the deep investing fascia of the lateral compartment.The anterior release can be seen here with bulging muscle.
    A puncture of the deep investing fascia is now made posterior to the superficial peroneal nerve, making sure to avoid damaging the nerve or the underlying peroneal muscle. An artery clip is used to grasp the fascia away from the superficial peroneal nerve and provide counter traction once again.

    Plan the proximal extent of the lateral compartment release.The estimated depth of the smiley knifes passage into the lateral compartment is determined by laying it against the skin to assess how deep it needs to be passed to effectively release the proximal margin of compartment.
    As can be seen its curve now passes posteriorly to avoid damage to the superficial peroneal nerve.

    Engage the Smiley knife to the deep investing fascia of the lateral compartment.Using counter traction with the artery clip the smiley knife is now passed into the small slit in the fascia, the long prong deep short fork of the prong superficial and the curve passing posteriorly.

    Release the lateral compartment from distal to proximal.The smiley knife is now introduced in one controlled sweeping manoeuvre, maintaining pressure on the thumpiece. The tactile feedback as this divides very much like the feeling of cutting a sheet of fabric with a pair of scissors. The knife is passed to the predetermined depth to release the compartment completely.

    Now a pocket is made superficial to the deep fascia, extending distally from the skin incision in order to allow release of the distal compartment and to ensure that the superficial peroneal nerve is not damaged as the Smiley knife is passed distally.

    Creating a distal pocket between the deep and superficial fasciae of the anterior compartment.A plane is developed distally between the subcutaneous and deep investing fasciae, this helps identify any variant divisions of the Superficial peroneal nerve, to create a space for passage of the smiley knife and to reduce the risk of nerve injury.

    Creating a distal pocket in the plane between the deep and superficial fascia of the lateral compartment.The plane between the deep and superficial fascia of the lateral compartment is developed distally with blunt dissection posterior to the superficial peroneal nerve.

    Release the distal aspect of the anterior compartment, followed by the distal lateral compartment using a smiley knife.The knife is engaged in the distal limb of the deep fascia and with firm pressure is passed distally, ensuring not to release the superior extensor retinaculum, as this may lead to bowstringing of the extensors. The smiley knife is angled anteriorly whilst maintaining counter traction with the artery clip.

    Using counter traction the lateral compartment is released distally posterior to the superficial peroneal nerve, and ensuring that the superior peroneal retinaculum is not divided.

    The final step is careful neurolysis of the superficial peroneal nerve as it exits the deep investing fascia.

    The superficial peroneal nerve can be seen non-compressed and free.

    Assess the decompression using soft tissue retractors to allow visual inspection.Adequately decompressed anterior and peroneal compartments, the muscle is seen to be clear now bulging through. Ensure that there are no residual constricting bands of fascia that may lead to persistent compression.

    Deflation the tourniquet before the end of the procedure and deal with bleeding points. I routinely release the tourniquet to assess for any significant deep bleeders. A swab is used to stem reactive bleeding from small vessels.

    Post-operative bleeding is cauterised using diathermy.

    The author closes in multiple layers, it is important not to close the deep fascia, which will raise the compartment pressure once more, the subcutaneous fat is closed in two layers.

    A subcuticular stitch to the skin is reinforced with an interrupted stitch, the reason for such meticulous closure is the patient’s are encouraged to actively mobilise post-operative and in our experience this reduces the risk of post-operative wound dehiscence.

    The image shows interrupted mattress sutures.

    Operation – 3

    A dry dressing is applied to the wound.

    A compressive bandage is applied from just below the knee to the metatarsal heads.

    Post Operative

    Patients are encouraged to elevate the leg regularly for 2 weeks. Local anaesthetic is administered for post-operative pain; patient’s are advised to take analgesia regularly for three days, followed by as required.
    It is important to manage the swelling post-operatively whilst elevating the leg as much as possible but on a regular basis (5 minutes out of every 30 minutes) Patients are encouraged to exercise, and especially activate their anterior compartment by walking upstairs or walking on their heels. The outer dressings are reduced leaving the small adhesive dress at 72 hours and ice packs or a cryocuff are applied to the calf in order to manage the post-operative swelling. The patient attends dressing clinic at two week to remove the adhesive dressing and then are allowed to bathe, massage the scar and are referred for physiotherapy to work on gait posture, strengthening the anterior compartments. They are allowed to return to general impact activities at 6 weeks and full sports by 10-12 weeks post-operatively.

    Recommended Reading

    1. Eur J Orthop Surg Traumatol. 2019 Feb;29(2):479-485. Fasciotomy for chronic exertional compartment syndrome of the leg: clinical outcome in a large retrospective group.
    Tam JPH, Gibson AGF, Murray JRD, Hassaballa M.
    Tam et al showed that there was a good correlation between pain levels and raised intracompartmental pressure, when they retrospectively reviewed 138 cases over 17 years. The group found that compartment pressure release in CECS significantly reduced pain and increased activity levels in their cohort.
    2 Orthop J Sports Med. 2017 Nov 10;5(11). Functional outcomes after surgical management of Isolated Anterolateral Leg Chronic Exertional Compartment Syndrome.
    Gatenby G. Haysom S. Twaddle B. Walsh S.
    Gatenby et al, in their retrospective study of 36 isolated anterior and lateral compartment releases for CECS in 20 patients, published in the November 2017 Orthopaedic Journal of Sports Medicine, reported excellent outcomes, with improved pain scores, a very low recurrence rate, 90% of patients returned to their pre-morbid level of sport.
    3. BMJ Open Sport Exerc Med. 2019 Mar 19;5(1). Conservative treatment of anterior chronic exertional syndrome in the military, with a mid-term follow up.
    Zimmermann WO, Hutchinson MR, Van den Berg R, Hoencamp R, Backx FJG, Bakker EWP.
    Zimmermann, et al published a retrospective study of a cohort of 75 military patients who were surgically eligible with a diagnosis of CECS or medial tibial stress syndrome, who were treated non-operatively with gait retraining and physical therapy, there was no difference in response between the two groups, at 2 years 57% of patients had maintained a return to active service. They concluded that physical therapy and gait retraining can improve symptoms in a significant population of patients presenting with CECS in a military setting, this may reduce the need for surgical fasciotomy.

    4. Arch Orthop Trauma Surg. 2017 Jan;137(1):73-79. Single minimal incision fasciotomy for the treatment of chronic exertional compartment syndrome: outcomes and complications.
    Drexler M, Rutenberg TF, Rozen N, Warschawski Y, Rath E, Chechik O, Rachevsky G, Morag G.
    11. Am J Sports Med. 1990 Jan-Feb;18(1):35-40. Modified criteria for objective diagnosis of chronic exertional compartment syndrome of the leg.
    Pedowitz RA, Hargens AR, Mubarak SJ, Gershuni DH.
    Pedowitz et al proposed the criteria for objective diagnosis of chronic exertional compartment syndrome. They proposed that with positive clinical findings, one or more of the following intramuscular pressure criteria were likely to be diagnostic of CECS of the leg
    1) a pre-exercise pressure greater than or equal to 15 mm Hg,
    2) a 1 minute postexercise pressure of greater than or equal to 30 mm Hg, or
    3) a 5 minute postexercise pressure greater than or equal to 20 mm Hg.
    12. J Phys Ther Sci. 2018 Aug:30(8):1056-1062. Running mechanics of females with bilateral compartment syndrome.
    Sugimoto D, Brilliant AN, d’Hemecourt DA, d’Hemecourt CA, Morse JM, d’Hemecourt PA.
    Compared to healthy female runners, bilateral CECS female runners demonstrated different running mechanics including greater overstride and ankle DF angles. The two variables were strongly associated with each other in bilateral CECS female runners, but not in healthy female runners. This may potentially contribute to the mechanism of CECS development.
    Tam et al showed that there was a good correlation between pain levels and raised intracompartmental pressure, when they retrospectively reviewed 138 cases over 17 years. The group found that compartment pressure release in CECS significantly reduced pain and increased activity levels in their cohort.
    Gatenby et al, in their retrospective study of 36 isolated anterior and lateral compartment releases for CECS in 20 patients, published in the November 2017 Orthopaedic Journal of Sports Medicine, reported excellent outcomes, with improved pain scores, a very low recurrence rate, 90% of patients returned to their pre-morbid level of sport.
    3. BMJ Open Sport Exerc Med. 2019 Mar 19;5(1). Conservative treatment of anterior chronic exertional syndrome in the military, with a mid-term follow up.
    Zimmermann WO, Hutchinson MR, Van den Berg R, Hoencamp R, Backx FJG, Bakker EWP.
    Zimmermann, et al published a retrospective study of a cohort of 75 military patients who were surgically eligible with a diagnosis of CECS or medial tibial stress syndrome, who were treated non-operatively with gait retraining and physical therapy, there was no difference in response between the two groups, at 2 years 57% of patients had maintained a return to active service. They concluded that physical therapy and gait retraining can improve symptoms in a significant population of patients presenting with CECS in a military setting, this may reduce the need for surgical fasciotomy.

    4. Arch Orthop Trauma Surg. 2017 Jan;137(1):73-79. Single minimal incision fasciotomy for the treatment of chronic exertional compartment syndrome: outcomes and complications.
    Drexler M, Rutenberg TF, Rozen N, Warschawski Y, Rath E, Chechik O, Rachevsky G, Morag G.
    11. Am J Sports Med. 1990 Jan-Feb;18(1):35-40. Modified criteria for objective diagnosis of chronic exertional compartment syndrome of the leg.
    Pedowitz RA, Hargens AR, Mubarak SJ, Gershuni DH.
    Pedowitz et al proposed the criteria for objective diagnosis of chronic exertional compartment syndrome. They proposed that with positive clinical findings, one or more of the following intramuscular pressure criteria were likely to be diagnostic of CECS of the leg
    1) a pre-exercise pressure greater than or equal to 15 mm Hg,
    2) a 1 minute postexercise pressure of greater than or equal to 30 mm Hg, or
    3) a 5 minute postexercise pressure greater than or equal to 20 mm Hg.
    12. J Phys Ther Sci. 2018 Aug:30(8):1056-1062. Running mechanics of females with bilateral compartment syndrome.
    Sugimoto D, Brilliant AN, d’Hemecourt DA, d’Hemecourt CA, Morse JM, d’Hemecourt PA.
    Compared to healthy female runners, bilateral CECS female runners demonstrated different running mechanics including greater overstride and ankle DF angles. The two variables were strongly associated with each other in bilateral CECS female runners, but not in healthy female runners. This may potentially contribute to the mechanism of CECS development.

    4. Arch Orthop Trauma Surg. 2017 Jan;137(1):73-79. Single minimal incision fasciotomy for the treatment of chronic exertional compartment syndrome: outcomes and complications.
    Drexler M, Rutenberg TF, Rozen N, Warschawski Y, Rath E, Chechik O, Rachevsky G, Morag G.
    Drexler et al reported a retrospective series of 95 legs undergoing a single minimal incision fasciotomy for the treatment of CECS, in whom there was a 75% satisfaction rate, they reported 2 wound complications, 8 recurrences and 4 nerve injuries. They concluded single incision fasciotomy provided a long term improvement in function and symptoms.
    5. J Orthop Surg Res. 2016 May 24;11(1):61. Single minimal incision fasciotomy for chronic exertional compartment syndrome of the lower leg.
    Maffulli N, Loppini M, Spiezia F, D’Addona A, Maffulli GD.
    Maffulli et al published a retrospective study of 18 athletes, with CECS who underwent a single, minimal incision fasciotomy. They reported high satisfaction rates, 17 of the 18 athletes returned to the same or higher level of activity than pre injury level, mean return to sporting activity was 8-13 weeks.

    6. J Bone Joint Surg Am. 1983 Dec;65(9):1245-51. The surgical treatment of exertional compartment syndrome in athletes.
    Rorabeck CH, Bourne RB, Fowler PJ.
    Rorabeck et al looked at 12 athletes, retrospectively in the Journal of Bone and Joint Surgery Am. 1983. They found that all patients in the group with purely anterior symptoms achieved complete pain relief following fasciotomy, however, those with associated posterior compartment involvement had a higher recurrence rate following fasciotomy.

    7. Eur J Orthop Surg Traumatol. 2014 Oct;24(7):1223-8. Return to activity following fasciotomy for chronic exertional compartment syndrome.
    Irion V, Magnussen RA, Miller TL, Kaeding CC.
    Irion et al looked at return to play in elite athletes. In those with anterior/lateral compartment release the mean return to sport was 10.6 weeks following fascial release. Those with a four compartment release experienced a longer return to sporting activity. They concluded that fasciotomy was a reliable treatment which allowed elite athletes to return to sports.
    8. J R Army Med Corps. 2015 Mar;161(1):42-5. Outcomes of surgery for chronic exertional compartment syndrome in a military population.
    Roberts AJ, Krishnasamy P, Quayle JM, Houghton JM.
    Roberts et al reported that whilst 49% of patients with CECS experienced an improvement in symptoms post surgical release of the fascia, however they found 36% were no better and 15% were worse off. They highlight that the results of compartment release in a military population were not in line with the results of a civilian or athletic population, however the reasons for this are unclear.
    9. Arthroscopy. 2016 Jul;32(7):1478-86. Surgical Management for Chronic Exertional Compartment Syndrome of the Lower Leg: A Systematic Review of the Literature.
    Compano D, Robaina JA, Kusnezov N, Dunn JC, Waterman BR.
    Compano et al presented a systematic review of the literature on the surgical management for chronic exertional compartment syndrome. They included 24 studies with 1596 patients undergoing open fasciotomy; 54% were military personnel 29% were athletes. The most frequently affected compartment was the anterior compartment (51%) , the lateral compartment(33%), the deep posterior (13%) and the superficial compartment was involved in 3%. 84% were satisfied with the outcome. The study explains that it is difficult to extrapolate these results to the newer small single incision procedures or arthroscopic fasciotomy.
    10. J R Army Med Corps. 2018 Sep;164(5):338-342. Effects of anterior compartment fasciotomy on intramuscular compartment pressure in patients with chronic exertional compartment syndrome.
    Roscoe D, Roberts AJ, Hulse D, Shaheen AF, Hughes MP, Bennett AN.
    Roscoe et al, compared 20 post fasciotomy patients with 20 patients with CECS who had not undergone surgery and 20 asymptomatic patients. THe post operative cohort had intracompartmental pressures lower than the preoperative group and there was no significant difference between their readings and asymptomatic controls.

    7. Eur J Orthop Surg Traumatol. 2014 Oct;24(7):1223-8. Return to activity following fasciotomy for chronic exertional compartment syndrome.
    Irion V, Magnussen RA, Miller TL, Kaeding CC.

    Reference

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